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CPE-008 · synthetic case ADR-FX-22
Primary pattern, antibodies already done
The cause work-up continues.
Purpose: The cause work-up continues.
Inputs the engine received
Cortisol testing
- 8 am total cortisol
- 4 µg/dL
- ACTH
- 120 pg/mL
- 21-hydroxylase antibodies already done
- Yes
Chemistry and vitals
- Age
- 46 years
What the engine reports
Detected clinical pattern
Pattern of Primary Adrenal Insufficiency
Low cortisol with ACTH above the upper limit (120 pg/mL). Add renin and aldosterone and look for the cause.
- Axis: Primary pattern (ACTH raised)
Why this pattern was identified
- Morning cortisol. 4 µg/dL: adrenal insufficiency is very likely (Endocrine Society; consensus statement).
Recommended next steps
For physician consideration. Urgent review always comes first.
- 121-hydroxylase antibodies were done: if negative, consider adrenal imaging and tuberculosis, hemorrhage, metastases, infection and adrenoleukodystrophy.
- 2Add renin and aldosterone to define mineralocorticoid deficiency.
Evidence and rule trace · 3 rules
AI-04Morning cortisol band
Inputs: 8 am cortisol 4 µg/dL
Adrenal insufficiency very likely (<5 µg/dL).
AI-06Primary pattern
Inputs: cortisol 4 µg/dL · ACTH 120 pg/mL (upper limit 46)
Pattern of primary adrenal insufficiency.
AI-08Work-up of the cause in primary pattern
Inputs: primary pattern
Autoimmune adrenalitis is the most common cause.
Evidence
- EV-ES-PAI-2016 · Bornstein SR, Allolio B, Arlt W, et al. Diagnosis and Treatment of Primary Adrenal Insufficiency: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2016;101(2):364-389.
- EV-HUSEBYE-2014 · Husebye ES, Allolio B, Arlt W, et al. Consensus statement on the diagnosis, treatment and follow-up of patients with primary adrenal insufficiency. J Intern Med. 2014;275(2):104-115.
Physician adjudication required. Clinical decision support for physician review. This output identifies laboratory patterns and safety situations. It does not diagnose adrenal insufficiency, name a glucocorticoid dose, or replace emergency treatment. Physician adjudication is required.
Change the values
The same engine, starting from this case. Change any value and watch the pattern and the rule trace react.
Morning cortisol bands
Cortisol testing
- <5 very likely
- 5–14.9 indeterminate
- ≥15 unlikely
46 pg/mL is assumed when empty.
Chemistry and vitals
Symptoms and signs
Exposures, history and context
More adrenal cases
ADR-FX-01
Low sodium, high potassium, weight loss and nausea
A 44-year-old with hyperpigmented scars.
ADR-FX-02
Hyperpigmentation and fatigue
No labs yet.
ADR-FX-03
Salt craving and dizziness on standing
Low sodium.
ADR-FX-04
Cortisol 2.1 with ACTH 180
Low cortisol and high ACTH: a primary pattern.
ADR-FX-05
Morning cortisol 9 µg/dL
Indeterminate.
ADR-FX-06
Morning cortisol 17 µg/dL
Unlikely.
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